What are the American Academy of Pediatrics (AAP) guidelines for treating neonatal jaundice?

AAP Guidelines for Neonatal Jaundice Management

Risk Assessment and Screening

The American Academy of Pediatrics (AAP) recommends universal risk assessment for hyperbilirubinemia in all newborns ≥35 weeks gestation before discharge, using either total serum bilirubin (TSB)/transcutaneous bilirubin (TcB) measurement or assessment of clinical risk factors. 1

• Before discharge, every newborn should be assessed for risk of developing severe hyperbilirubinemia 1
• Two clinical options for risk assessment (can be used individually or in combination):
  • Predischarge measurement of bilirubin level using TSB or TcB 1
  • Assessment of clinical risk factors 1

Major Risk Factors (in order of importance)

• Predischarge TSB/TcB level in high-risk zone on nomogram 1
• Jaundice observed in first 24 hours of life 1
• Blood group incompatibility with positive direct antiglobulin test or other hemolytic disease 1
• Gestational age 35-36 weeks 1
• Previous sibling who received phototherapy 1
• Cephalohematoma or significant bruising 1
• Exclusive breastfeeding with poor nursing and excessive weight loss 1
• East Asian race 1

Follow-up Recommendations

• All infants should be examined by a qualified healthcare professional within the first few days after discharge 1
• Follow-up timing based on discharge age:
  • Discharge <24 hours: follow-up by 72 hours of age 1
  • Discharge 24-47.9 hours: follow-up by 96 hours of age 1
  • Discharge 48-72 hours: follow-up by 120 hours of age 1
• Earlier or more frequent follow-up for infants with risk factors 1
• If appropriate follow-up cannot be ensured for high-risk infants, consider delaying discharge until follow-up can be arranged or until the period of greatest risk has passed (72-96 hours) 1

Assessment During Follow-up

• Follow-up assessment should include:
  • Weight and percent change from birth weight 1
  • Adequacy of intake 1
  • Pattern of voiding and stooling 1
  • Presence or absence of jaundice 1
• If there is any doubt about jaundice severity, measure TSB or TcB 1
• Visual estimation of bilirubin levels can lead to errors, especially in darkly pigmented infants 1

Treatment Guidelines

Phototherapy

Phototherapy should be initiated based on TSB levels that exceed thresholds on the AAP nomogram, which vary according to the infant's age in hours and risk category (low, medium, or high risk). 1

• Intensive phototherapy should deliver irradiance in the blue-green spectrum (430-490 nm) of at least 30 μW·cm−2·nm−1 1
• Irradiance should be measured at the infant's skin directly below the center of the phototherapy unit 1
• Phototherapy should be delivered to as much of the infant's surface area as possible 1
• If TSB levels approach or exceed exchange transfusion thresholds, line the sides of the bassinet/incubator with aluminum foil or white material to increase efficacy 1

Monitoring During Phototherapy

• For TSB ≥25 mg/dL (428 μmol/L): repeat TSB within 2-3 hours 1
• For TSB 20-25 mg/dL (342-428 μmol/L): repeat within 3-4 hours 1
• For TSB <20 mg/dL (342 μmol/L): repeat in 4-6 hours 1
• If TSB continues to fall, repeat in 8-12 hours 1
• Discontinue phototherapy when TSB <13-14 mg/dL (239 μmol/L) 1
• Consider measuring TSB 24 hours after discontinuing phototherapy to check for rebound 1

Breastfeeding Management

• In breastfed infants requiring phototherapy, continue breastfeeding if possible 1
• Breastfeed or bottle-feed (formula or expressed breast milk) every 2-3 hours during phototherapy 1
• Supplementation with expressed breast milk or formula is appropriate if:
  • Infant's intake seems inadequate 1
  • Weight loss is excessive 1
  • Infant appears dehydrated 1
• Temporary interruption of breastfeeding with formula substitution is an option to reduce bilirubin levels and enhance phototherapy efficacy 1

Additional Laboratory Considerations

• When using guidelines for phototherapy, do not subtract direct (conjugated) bilirubin from total bilirubin 1
• Consider measuring serum albumin level; albumin <3.0 g/dL is a risk factor for lowering phototherapy threshold 1
• For exchange transfusion consideration, measure albumin and use bilirubin/albumin ratio along with TSB level 1

Exchange Transfusion

• Immediate exchange transfusion is recommended for any jaundiced infant showing signs of intermediate to advanced acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry), even if TSB is falling 1
• For infants with isoimmune hemolytic disease and rapidly rising TSB despite intensive phototherapy, administer intravenous immunoglobulin 0.5-1 g/kg over 2 hours and repeat in 12 hours if necessary 1

Special Considerations

• Changing the infant's position during phototherapy has not been demonstrated to improve effectiveness 1
• Using multiple phototherapy devices can be more effective than changing position 1
• If TSB does not decrease or continues to rise during intensive phototherapy, hemolysis should be suspected 1
• The clinical impact of phototherapy should become evident within 4 hours with an anticipated decrease in TSB >2 mg/dL 1

Parent Education

• All hospitals should provide written and verbal information for parents at discharge about:
  • Explanation of jaundice 1
  • Need to monitor infants for jaundice 1
  • Advice on how monitoring should be done 1

These guidelines are designed to prevent severe hyperbilirubinemia and bilirubin encephalopathy while minimizing unnecessary treatment and separation of mothers and infants.